Netsanet Bekele, cq, a clinical lab scientist for the Minnesota Health Department test for measles as he places the tubes into a robot, Thursday, May 11, 2017 at the MHD laboratories in St. Paul, MN.

State health officials got the troubling news last Thursday: A Minneapolis child care center was not cooperating with efforts to stop the spread of measles, and the problem was getting worse.

For nearly four weeks, the Minnesota Department of Health had been battling a measles outbreak that is now the state’s worst since 1990. The Minneapolis day care center was one of 11 where infected children have exposed thousands of others — many unvaccinated — leading to an outbreak that has sickened 54 people and spread to rural parts of the state. And now the center was refusing to cooperate with Health Department instructions.

“We could continue to see new cases from this,” said Jennifer Heath, who leads the department’s efforts with child care centers and schools.

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After a brief discussion, Heath and the group decided to contact the state Department of Human Services, which oversees child care providers, and ask for enforcement help.

It was just one item of business on a busy morning for the Health Department’s measles incident command team, which has been convening daily since shortly after the outbreak began to monitor new cases, review infection control efforts and coordinate with local public health officials.

Incident command, which includes about two dozen leaders from various corners of the Health Department, oversees a vast network of efforts across the Twin Cities and the state. So far, it has identified more than 7,000 people exposed to the virus at the child care centers, three schools and about 20 health care settings. Nearly 500 people have been asked to limit public contact because they lack immunity protection.

A major part of the control effort is finding people who have been exposed to known cases, especially people who don’t have immunity. By intervening with them early, public health officials can potentially prevent them from getting sick and infecting others.

“You want to get ahead of the outbreak and catch cases early,” said Melissa McMahon, one of the department epidemiologists tapped to help.

Surge in vaccinations

Already, the team has notched some major successes. Outreach efforts by state and local agencies, health care providers and community leaders have driven a dramatic spike in the number of Somali-American children receiving the MMR vaccine, which protects against measles, mumps and rubella.

Low vaccination rates among Somalis had set the stage for the spread of the disease in child care centers. As a result, 47 of the cases have been in Somali-Americans, mostly children.

But in the past four weeks, nearly 1,600 Somali children have been vaccinated — up from just 140 in the month before the outbreak.

“The more people you get that are not susceptible makes it harder and harder for the virus to get to those who are susceptible,” said Kris Ehresmann, infectious disease director at the Health Department. “It is all about building that wall around the virus.”

Still, the team continues to encounter fresh challenges as the outbreak enters its fifth week.

As of late last week, health officials were watching some possible new infections in Le Sueur County, which would extend the outbreak to the second county outside the metro area. That situation is linked to four cases in unvaccinated children in Crow Wing County, where exposure occurred through a family gathering.

Another pool of potential exposures could come to light soon. An employee of a Hennepin County hotel is one of the three adults to be sickened so far in this outbreak. State officials would not disclose the hotel name, but hotel employees have been notified and soon a letter will go out to guests, according to an update provided at Thursday’s incident meeting.

Hodan Hassan worked on a computer game with her daughter Geni Hassan, 6. Hassan said Geni spent more than four years in therapy. Hassan knows why some in the Minneapolis Somali community have feared vaccines. As the mother of an autistic child, she once believed there might be a link between vaccines and her daughter's condition. But no more. Hassan is scheduled to speak at a Somali community forum on Saturday, to encourage fellow parents to get their kids vaccinated in the face of an escalating measles outbreak. Elizabeth Flores/ STAR TRIBUNE

The need to stay on top of points of transmission is why the incident team was so troubled by the Minneapolis day care center. For nearly two weeks, Health Department officials had talked to the owner about the need to turn away any child with measles symptoms.

But the team learned that the problematic child care center had taken in a child with symptoms — in fact, the same child had been declined entry to one of the other 11 child care centers the same day. More importantly, the center refused to provide enrollment and attendance information that health officials need to find kids who were exposed.

“This is really the first one where they have been resistant to us,” Heath told the incident control group, noting that officials had visited the center and had gotten some names, but that the list was incomplete.

The incident team had already been working with Human Services, and by the end of the day Thursday the licensing agency had issued a temporary immediate suspension against the facility, First Daycare Center in Minneapolis. It can no longer operate until the order is successfully appealed. A facility representative could not be reached for comment Friday.

While department officials have been tracking exposures, the department’s laboratory has been busy testing nose and throat swabs collected by clinics and hospitals for the measles virus. With a national reputation for its testing and investigation abilities, the state lab has specialized equipment to analyze the samples to detect a particular gene that no other virus has.

They have been getting about 20 samples a day during the outbreak, in addition to nearly 200 other items each day that need testing for other illnesses. Because identifying new cases is so crucial to outbreak control, the lab tries to process the measles tests quickly, sometimes within five hours, said Anna Strain, head of the lab’s virology unit.

Altogether, the Health Department effort has tapped 70 of its employees, pulling some away from work on other disease control efforts, such as emerging infections, meningitis, foodborne illness and health care infections. It has cost the department more than $120,000, and if the outbreak continues for three months the cost could approach $1 million.

While the epidemiological data cannot forecast when the outbreak will run its course, it could be a while before new infections come to an end.